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Minimum Education
Bachelor's Degree (Preferred)
Minimum Work Experience
3 years Related patient accounting experience required, especially related to insurance overpayments trending and root cause analysis (Required)
Required Skills/Knowledge
Excellent working knowledge of complex contract reimbursement methodologies including transplant, global, APR DRGs among others.
Proven analytical skills including ability to make recommendations based on financial analysis.
Excellent PC skills including advanced skill proficiency in Access and Excel spreadsheet analysis.
Ability to work in a team environment with other analysts, managers, and department leaders.
Proficiency in presentation of analytical results.
Excellent working knowledge of coding & NCCI edits.
Demonstrated knowledge of managed care payer requirements in an acute hospital setting.
Demonstrated ability to facilitate team or group activities.
Excellent verbal and written communication skills.
Demonstrated ability to be flexible and to prioritize workload & decision-making skills.
Ability to analyze workflow for process improvement.
Strong organizational and coordination skills required.
Functional Accountabilities
Account Follow-up
- Ensure all assigned claims and encounters are reviewed in a timely manner as per standard operating procedure (SOP)
- Evaluate contract management expected reimbursement and follow appropriate guidelines to report and escalate discrepancies
- Assess overpayments and process timely as per procedures
- Rebill claim or issue refund as appropriate to facilitate payment retraction or refund
- Establish a system to ensure refund requests from insurance carriers are processed within 30 days of receipt
- Read and interpret payer contracts for accuracy when submitting refund request for approval
- Ensure appropriate supporting documentation is included with refunds
- Report state Medicaid’s credit balances on a quarterly basis
- Manage matrix of issues & resolutions including accountable stakeholders; ensure results and escalate issues as appropriate; regularly report updates and challenges to manager
- Conduct root cause analysis of issues affecting overpayments. Identify key issues and assist in tracking, trending and reporting
- Present data and analysis clearly to all levels of staff and management
- Meet with manager and outside departments to review issues and develop action plans
- Assist in development of solutions, training & education guidelines to resolve issues and share data with staff and management
- Appropriately engage and involve key accountable stakeholders in a collaborative manner
- Research payer & CMS policies related to revenue cycle; identify & alert stakeholders of required changes; track and ensure completions
Organizational Accountabilities
Track Refunds
- Maintain a refund request log to monitor the request, issuance, mailing and posting of refunds.
- Provide supporting documentation to Accounts Payable with completed signatures and back up.
- Partner in the mission and upholds the core principles of the organization
- Committed to diversity and recognizes value of cultural ethnic differences
- Demonstrate personal and professional integrity
- Maintain confidentiality at all times
- Anticipate and responds to customer needs; follows up until needs are met
- Demonstrate collaborative and respectful behavior
- Partner with all team members to achieve goals
- Receptive to others’ ideas and opinions
- Contribute to a positive work environment
- Demonstrate flexibility and willingness to change
- Identify opportunities to improve clinical and administrative processes
- Make appropriate decisions, using sound judgment
- Use resources efficiently
- Search for less costly ways of doing things
Organizational Commitment/Identification
- Anticipate and responds to customer needs; follows up until needs are met
Teamwork/Communication
- Demonstrate collaborative and respectful behavior
- Partner with all team members to achieve goals
- Receptive to others’ ideas and opinions
Performance Improvement/Problem-solving
- Contribute to a positive work environment
- Demonstrate flexibility and willingness to change
- Identify opportunities to improve clinical and administrative processes
- Make appropriate decisions, using sound judgment
Cost Management/Financial Responsibility
- Use resources efficiently
- Search for less costly ways of doing things
Safety
- Speak up when team members appear to exhibit unsafe behavior or performance
- Continuously validate and verify information needed for decision making or documentation
- Stop in the face of uncertainty and takes time to resolve the situation
- Demonstrate accurate, clear and timely verbal and written communication
- Actively promote safety for patients, families, visitors and co-workers
- Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance
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